Transrectal ultrasound and prostate biopsy

Rationale and key points

This How to module aims to help nurses to support patients who require a prostate biopsy to diagnose or exclude prostate cancer. Nurses will also gain an understanding of the procedure for transrectal biopsy.

• A transrectal biopsy is commonly used to access the prostate.
• Indications for a biopsy include elevated levels of prostate-specific antigen (PSA) in the blood, identification of abnormal areas on digital rectal examination and active surveillance of low-risk prostate cancer.
• The healthcare practitioner uses an ultrasound probe to guide them to specific areas of the prostate to obtain biopsy specimens.

Keywords

clinical procedures, clinical skills, prostate biopsy, prostate cancer, transrectal biopsy, transrectal ultrasound

Learning objectives

After reading this module you should be able to:

• List the preparatory steps and equipment needed to perform a prostate biopsy.
• Explain how to perform a transrectal biopsy of the prostate.
• Discuss the potential post-biopsy complications with the patient.
• Understand the psychological support needs of patients undergoing prostate biopsy.

Preparation and equipment

Transrectal biopsy of the prostate is undertaken by a nurse skilled and competent in performing this advanced skill, urologist or radiologist.

Room preparation

The healthcare practitioner should ensure the necessary equipment is available, including:

• Examination couch.
• Curtains or a screen to ensure privacy.
• Ultrasound machine.
• Linen skip.
• Clinical waste bin.
• Sharps bin.
• Gloves and an apron.
• Wipes or gauze.
• Hospital gown or a sheet.
• Incontinence pad.
• Clinical trolley for other equipment.

They should also ensure there is access to emergency equipment and an appropriate medical emergency team.

Equipment wheel – room preparation

Patient preparation

It is important to remember that the patient is undergoing a prostate biopsy that may confirm cancer. Therefore, he may show signs of stress and anxiety, and may have questions about the treatment and management of prostate cancer. The healthcare practitioner should be aware of this and provide support and reassurance as necessary.

The healthcare practitioner should:

• Confirm the correct patient and correct procedure.
• Explain the procedure to the patient and discuss associated risks.
• Ensure any allergies have been confirmed, for example to latex, antibiotics and local anaesthetic.
• Obtain a signed consent form for the procedure.
• Provide the patient with a post-biopsy information leaflet at the appropriate point.
• Ensure the patient has taken prophylactic antibiotics and that anti-platelet medication has been stopped in accordance with local guidelines.
• Provide a gown or sheet to cover the patient.
• Provide a procedure pad to protect the patient's clothing during the biopsy.

Clinical trolley preparation

The healthcare practitioner should cover a clean clinical trolley with a sterile dressing pack and lay out the following items:

• Ultrasound probe:
  • Decontaminated transrectal ultrasound probe.
  • Probe cover.
  • Needle guide.
  • Lubricating gel.
• Local anaesthetic administration:
  • 10mL syringe.
  • Local anaesthetic, for example lidocaine 1%. Follow any local policy or guidance.
  • Spinal needle – long enough to fit down the needle guide.
• Histology specimens:
• Biopsy needle.
• Several histopathology specimen pots.
• Histopathology request form.
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• Learning Points 
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• Indications for a biopsy include elevated levels of prostate-specific antigen (PSA) in the blood, identification of abnormal areas on digital rectal examination and active surveillance of low-risk prostate cancer.
• Before undertaking a prostate biopsy, the healthcare practitioner should introduce themselves, check the patient’s identity, explain the procedure to the patient as well as any symptoms they might experience following the procedure, and obtain the patient’s consent to carry out the procedure.
• It is important to ensure that the patient has taken prophylactic antibiotics and that anti-platelet medication has been stopped, according to local policy or guidance.

Procedure
Position the patient on the examination couch in the left lateral position, with the anus exposed.	Perform a digital rectal examination of the prostate to identify any areas that feel abnormal.
Lubricate the ultrasound probe with the lubricating gel, then fit a probe cover. Gently insert the probe into the patient's rectum to perform ultrasound assessment of the prostate.	Infiltrate a local anaesthetic, for example lidocaine 1% using the 10mL syringe, into the periprostatic space. Confirm with the patient that adequate pain relief has been provided.
Undertake measurement of the prostate volume to assess the size of the prostate gland.	Identify appropriate locations from the apex, middle and base of the prostate gland, and any hypoechoic lesions where the biopsy samples should be taken from.
Introduce the biopsy needle through the needle guide on the ultrasound probe. Guide the needle through the rectal wall into the prostate and biopsy. Repeat this process to obtain additional biopsy specimens.	Place each biopsy specimen into a separate histopathology specimen pot and ensure each pot is labelled accurately.
Assess the patient for any complications following the procedure.	Use wipes or gauze to clean the area around the anus, which may be blood stained.
Apply a procedure pad in case of leakage of blood from the anus. Ask the patient to dress themselves, assisting as needed.	Dispose of used equipment appropriately, for example, place the biopsy needle in the sharps bin and clinical waste in the clinical waste disposal bin.
Remind the patient of potential post-biopsy complications, such as mild haematuria, rectal bleeding or haematospermia (blood in the semen).	Arrange a follow-up appointment to inform the patient of the results of the biopsy. Results usually take at least one week to be returned from the histopathology department.
Advise the patient to rest at home for a few hours following the procedure, drink plenty of fluids and attend the emergency department if there are signs of infection, such as fever or dysuria, if there is severe bleeding or if he cannot pass urine.